1. ARIES HCP Users Group Training Webinar Lorene Vanzandt, MPH Student Intern, UC Davis Dave Ranck, ARIES Help Desk California Department of Public Health Office of AIDS Care Branch Quality Management Program November 2, 2011 QUALITY MANAGEMENT FOR MEASURE 3

2. Quality Management-Why is it so important? How well does QM work to improve client outcomes? Fortune 500 CEO compared to CDPH Office of AIDS

3. HIV Care Program (HCP) Quality Management Plan The Office of AIDS is continuing to monitor the 5 clinical indicators for HIV/AIDS care providers. HRSA requires grantees and their providers to establish QM programs that: Monitor and analyze data entered by the provider Assess the findings/provider scores Use the data to assist providers and improve outcomes

4. Clinical Indicators for HCP Medical Providers 1. Clients with HIV who had 2 or more medical visits at least three months apart in an HIV care setting in the measurement year OA Benchmark – 75% 2. Clients with HIV who had 2 or more CD4 T-cell counts performed at least 3 months apart during measurement year OA Benchmark – 75% 3. Clients with HIV and a CD4 T-cell count below 200 cells/mm3 who were prescribed PCP prophylaxis OA Benchmark 75% 12a. AIDS-diagnosed clients that are prescribed highly active antiretroviral therapy (HAART) OA Benchmark – 75% 17. Pregnant women with HIV who are prescribed antiretroviral therapy during 2nd and 3rd trimester in measurement year OA Benchmark - 100%

5. Non-clinical Indicators for All HCP Providers Percentage of: Clients with documentation of HIV status 75% Clients with a calculated federal poverty level indicated 95% Clients with documentation of insurance 95% For more information about these indicators, please read the Office of AIDS Management Memo 11-01: Policy on Quality Management Indicators

6. HIV/AIDS Bureau (HAB) Measure 3 – PCP Prophylaxis Percentage of clients with HIV infection and a CD4 T-cell count below 200 cells/mm3 who were prescribed PCP prophylaxis

7. Some definitions first……… CD4 T-cell—the human body’s immune cells (WBCs) that HIV inhabits and destroys CD4 count plays an integral role in determining the stage of HIV. HIV attacking White Blood Cell CD4 count Indicates the need for prophylaxis against opportunistic infections. Used in decisions regarding initiation or adjustment of antiretroviral therapy.

8. Some definitions first……… Prophylaxis Pneumocystis Pneumonia (PCP) Pneumocystis fungi almost always infect the lungs, causing a virulent form of pneumonia. Prophylaxis is medication designed to prevent susceptible people (immunosuppressed and elderly) from contracting pneumonia Drugs used for PCP include: TMP/SMX (trimethoprim/sulfamethoxazole -- Septra, Bactrim), dapsone (Dapsone), pentamidine (Nebupent), atovaquone (Mepron) HAB HIV Core Clinical Performance Measures for Adult/Adolescent Clients: Group 1. Measure 3. Basis for selection and placement in Group 1.

9. Pneumocystis Pneumonia (PCP) Pneumocystis pneumonia, is a severe infection caused by a fungus called Pneumocystis jiroveci (carinii). Most people infected with this fungus don’t acquire PCP because their immune systems are healthy, but people with HIV have a very high chance of getting it. Before HIV medication was available, PCP occurred in 70%-85% percent of HIV-positive people. The number of cases has decreased a great deal. This is due to highly active antiretroviral therapy (HAART) and PCP-preventive drugs. Information--aids.about.com/cs/conditions/a/pcpguide.htm From Mark Cichocki, R.N., former About.com Guide. Updated May 12, 2009. Reviewed by the Medical Review Board Chart--The incidence of HIV-associated Pneumocystis pneumonia in the United States. depts.washington.edu

10. HAB Measure 3: PCP Prophylaxis Fact Sheet Is there a vaccine for PCP? No. The Pneumovax vaccine protects against Pneumococcal bacterial, but not against Pneumocystis Pneumonia. PCP can be prevented, which is key, especially if CD4 count is low (from 200-250 cells/mm3). The best prevention drug for PCP is the antibiotic Bactrim. If someone has an allergy to Bactrim, it can be replaced with Dapsone or pentamidine. If someone contracts PCP, they will probably be prescribed Bactrim, Septra, Dapsone, Nebupent, Mepron. HAB HIV Core Clinical Performance Measures for Adult/Adolescent Clients: Group 1 Measure 3 A Complete Guide aids.about.com/s/conditions/a/pcpguide.htm From Mark Cichocki, R.N., former About.com Guide Updated May 12, 2009 About.com Health's Disease and Condition content is reviewed by the Medical Review Board Pneumocystis carinii pneumonia iahealth.net

11. * PNEUMOCYSTIS PNEUMONIA (PCP) IS THE MOST COMMON OPPORTUNISTIC INFECTION IN PEOPLE WITH HIV. * WITHOUT TREATMENT, OVER 85% OF PEOPLE WITH HIV WOULD EVENTUALLY DEVELOP PCP. * IT IS THE MAJOR CAUSE OF DEATH AMONG PEOPLE WITH HIV INFECTION (MORTALITY RATE IS BETWEEN 20-40% IN PEOPLE WITH ACUTE IMMUNOSUPPRESSION, YET IT IS ALMOST ALWAYS PREVENTABLE AND TREATABLE). HAB HIV CORE CLINICAL PERFORMANCE MEASURES FOR ADULT/ADOLESCENT CLIENTS: GROUP 1. PERFORMANCE MEASURE: PCP PROPHYLAXIS. US DEPARTMENT OF HEALTH AND HUMAN SERVICES. HEALTH RESOURCES AND SERVICES ADMINISTRATION. HAB Measure 3. Why it’s Important

12. How well is HCP meeting Measure 3?

13. Summary~Providers and HAB Performance Measures: What is Your Responsibility? 1. ENTER AND TRACK DATA ON CLINICAL AND NON-MEDICAL INDICATORS TO MONITOR THE QUALITY OF CARE PROVIDED 2. RUN THE HAB QM REPORT IN ARIES TO GET BASELINE DATA FOR THE CLINICAL INDICATORS. 3. ASSESS DATA QUALITY AND RESOLVE ANY DATA ENTRY ERRORS.

14. 4. BEGIN THE PDSA CYCLE TO IDENTIFY AREAS FOR IMPROVEMENT AND INCLUDE THESE IN YOUR QUALITY MANAGEMENT PLAN 5. THERE IS A LOT OF RESEARCH ON HOW TO IMPROVE PCP PROPHYLAXIS ADHERENCE AMONG HIV CLIENTS 6. OBTAIN TECHNICAL ASSISTANCE TO HELP REACH BENCHMARK GOALS

15. 7. PERIODICALLY RERUN THE MEASURES IN ARIES TO SEE IF TECHNICAL ASSISTANCE AND INTERVENTIONS HAVE RESULTED IN IMPROVEMENT (THIS LEADS US TO THE PDSA CYCLE, COMING UP NEXT!) 8. IMPLEMENT CHANGES AS NECESSARY TO ACCURATELY TRACK AND ENSURE HIGH-QUALITY CLIENT CARE

16. The PDSA Cycle What happens when benchmarks are not met? Quality management staff collaborate with provider program specialists to develop and implement the Plan, Do, Study, Act cycle Plan-Plan a change Do-Try it out on a small scale Study-Observe the results Act-Refine the change as necessary PlanDoStudyAct

17. PDSA Cycle Institute for Healthcare Improvement 2002.

18. The Act Phase of the PDSA—3 A’s Adopt-change your overall plan according to the positive improvement you’ve seen Adapt-adjust part of your plan to revise on the road to improvement Abandon-choose another plan—therefore another PDSA cycle—to lead to success

19. QM Resources * To look up HAB medical measures, go to the HIV/AIDS Bureau habhrsa.gov/special/habmasures.html * For information on the HIVQUAL workbook, hab.hrsa.gov/deliverhivaidscare/hivqual.html * For providers who develop their own QM plan, refer to the 9 steps in HAB’s QM Technical Assistance Manual hab.hrsa.gov/tools/qm * For great trainings on quality management, go to the National Quality Center nationalqualitycenter.org/index.cfm * Pacific AIDS Education and Training Center has 11 Local Performance Sites in California that offer free training programs for healthcare teams designed to improve HIV/AIDS services, treatment and prevention paetc.org *More Ryan White Technical Assistance at the Target Center careacttarget.org

20. OA Contact Information ARIES Help Desk www.projectaries.org (866) 411-2743www.projectaries.org lorene.vanzandt@cdph.ca.gov (916) 449-5981 lorene.vanzandt@cdph.ca.gov Thank you!